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Simplifying effective treatment of chronic hives in children

Published Online June 7, 2014

Up to 20 percent of people get occasional hives. Some are the result of allergies or other physical causes, but for many people the cause is unknown—the medical term for which is “idiopathic.” Hives lasting longer than six weeks are considered to be chronic, and the medical diagnostic term for those of unknown cause is “chronic idiopathic urticaria” (urticaria and hives are essentially interchangeable terms). Hives cause considerable discomfort because they itch and their presence causes embarrassment. Some people respond readily to antihistamines, but some need additional therapy.

In a recent study published in The Journal of Allergy and Clinical Immunology: In Practice, Drs. Lisa Neverman and Miles Weinberger examined outcomes from treating chronic idiopathic urticaria in 46 children referred to the Allergy, Immunology, and Pulmonary Clinic at the University of Iowa Children’s Hospital. They also examined whether the presence of autoimmune antibodies affected outcome.

The average duration of hives prior to being seen in the clinic was more than seven months. Initially, everyone was treated with the antihistamine hydroxyzine, or cetirizine, the active product of ingested hydroxyzine. Those who did not respond to one of those medications with a complete suppression of their daily hives then received cyclosporine, in closely monitored doses to ensure safety.

Many of the children treated in the clinic responded to one of the two antihistamines. However, 35% had hives resistant to even high doses of the antihistamines. The doctors found that those with hives resistant to antihistamines were generally older children, with an average age of 12 years. All thirteen children under the age of nine had their chronic hives controlled with the antihistamines. The presence of autoimmune antibodies were not associated with a lack of benefit from antihistamines. All children had their hives completely suppressed by either the antihistamines or within days to a few weeks from the addition of cyclosporine. The average duration for continued use of cyclosporine was five months. When cyclosporine was stopped, most of the children remained free of hives. Only five of the 16 treated with cyclosporine had their hives return after an average of six months. No adverse effects were seen from either the antihistamines or cyclosporine.

By beginning treatment for chronic hives in children with the most effective antihistamines, and increasing the dose to obtain optimal benefit, those children whose hives were not suppressed by antihistamines could be readily identified in a timely manner. The authors concluded that rapid determination of whether patients benefit from hydroxyzine or cetirizine, and the addition of cyclosporine when needed, can provide safe, prompt, and complete relief for children with chronic hives.

The Journal of Allergy and Clinical Immunology: In Practice is an official journal of the AAAAI, focusing on practical information for the practicing clinician.